Second Line Drugs - WHO guidance

Second line drugs are the TB drugs that are used for the treatment of drug resistant TB. The second line drugs include Levofloxacin, Moxifloxacin, Bedaquiline and Linezolid. There is also Pretomanid which is a new second line drug recommended in 2019 for the treatment of drug resistant TB.

It needs to be emphasized that all the second line drugs should only be used under the supervision of an experienced doctor. Their use needs to take into account not only the World Health Organisation (WHO) recommendations, but also what is recommended by a country's National Treatment Program.1Emanuele Pontali et al, "Regimens to treat multidrug-resistant tuberculosis: past, present and future perspectives", 2019, European Respiratory review, https://err.ersjournals.com/content/28/152/190035#ref-32

Second line drugs - WHO Guidance

Amikacin, a second line injectable drug

Amikacin, a second line injectable drug

In 2019 WHO published new consolidated guidance on the second line drugs to be used for the treatment of drug resistant TB.2"WHO consolidated guidelines on drug-resistant tuberculosis treatment", 2019, Geneva, https://www.who.int/tb/publications/2019/consolidated-guidelines-drug-resistant-TB-treatment/en/ It is planned that there is also going to be a major update of the guidelines in 2020. It is said that the updated consolidated guidelines substantially changed the approach to the treatment of MDR-/XDR-TB.3Emanuele Pontali et al, "Regimens to treat multidrug-resistant tuberculosis: past, present and future perspectives", 2019, European Respiratory review, https://err.ersjournals.com/content/28/152/190035#ref-32

The updated consolidated guidelines address the role of both the longer and shorter treatment regimens and reclassify the drugs used to compose the longer (18-20 month) regimen into 3 groups (A, B and C) as shown below.4Emanuele Pontali et al, "Regimens to treat multidrug-resistant tuberculosis: past, present and future perspectives", 2019, European Respiratory review, https://err.ersjournals.com/content/28/152/190035#ref-32

Second line drugs for treatment of drug resistant TB (as of March 2019)
Group A : Group B : Group C :
levofloxacin (Lfx) or
moxifloxacin (Mfx)
clofazimine (Cfz) ethambutol (E)
bedaquiline (Bdq) cycloserine (Cs)
or terizidone (Trd)
delamanid (Dlm)
linezolid (Lzd) pyrazinamide (Z)
imipenem-cilastatin (Ipm-Cln) or
meropenem (Mpm)
amikacin (Am) (or streptomycin) (S)
ethionamide (Eto) or Prothionamide (Pto)
p-aminosalicylic acid (PAS)

If a plus sign is shown, clicking on it will show more columns.

WHO now recommends that all oral regimens should become the preferred option for most patients. It is a major step forward in the treatment of patients with drug resistant TB that most patients will no longer be required to have injectable drugs. It is essential that this is implemented as soon as possible because, as explained on the page about the treatment of drug resistant TB, for some patients injections can be extremely painful and difficult.

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This page was last updated in December 2019.
Author Annabel Kanabus

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